ERIC ED442032: Suicide Prevention in Juvenile Facilities.

DOCUMENT RESUME

ED 442 032

CG 030 030

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NOTE
PUB TYPE

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TITLE’

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JOURNAL CIT
EDRS PRICE
DESCRIPTORS

IDENTIFIERS

Hayes, Lindsay M.

Suicide Prevention in Juvenile Facilities.

Office of Juvenile Justice and Delinquent Prevention (Dept,
of Justice) , Washington, DC.

2000-04-00

lOp.

Journal Articles (080)

Juvenile Justice; v7 nl pp24-32 Apr 2000
MFOl/PCOl Plus Postage.

♦Adolescents ; Agency Cooperation; Case Studies; Evaluation;
High Risk Students; Housing; Interpersonal Communication;
Intervention; * Juvenile Justice; Policy; *Prevention;
Screening Tests; Staff Role; *Suicide; Supervision; Training
♦Adolescent Suicide

ABSTRACT

Youth suicide is recognized as a serious public health

problem, but suicide within juvenile facilities has not received comparable
attention, and the extent and nature of these deaths remain unknown. This
article utilizes an example of a young man in a juvenile justice facility who
succeeded in committing suicide to illustrate these points. Information
concerning risk factors for suicide and current conditions of confinement in
juvenile facilities is provided. The critical components of a suicide
prevention policy are discussed. Issues examined within this discussion
include: staff training; intake screening and ongoing assessment;
communication; housing; supervision; intervention; reporting; and follow-up.
Essential for suicide prevention in juvenile justice facilities are
collaborative efforts among child- serving agencies. Now is the time to focus
additional attention and resources on preventing suicide within these
facilities. (Contains 25 references.) (MKA)

Reproductions supplied by EDRS are the best that can be made
from the original document.

030030

Juvenile Justice

Suicide Prevention in

O

o Juvenile Facilities

by Lindsay M. Hayes

U.S. DEPARTMENT OF EDUCATION
Office of Educational Research and Improvement

EDUCATIONAL RESOURCES INFORMATION
CENTER (ERIC)

□ This document has been reproduced as
received from the person or organization
originating it.

□ Minor changes have been made to
improve reproduction quality.

Points of view or opinions stated in this
document do not necessarily represent
official OERI position or policy.

N

X kelson, a 16-year-old American Indian, was committed to the
Valley Youth Correctional Facility in May 1996 as a disposition for a
sexual assault.^ At an early age he had been physically abused by family
members and sexually abused by neighborhood youth. Although he had
never attempted suicide, Nelson had an extensive history of suicidal
thoughts and tendencies. Psychiatric evaluation led to a diagnosis of
conduct disorder and attention deficit hyperactivity disorder. The
facility’s psychiatrist saw him regularly and prescribed psychotropic
medication. In October 1996, Nelson was placed on suicide watch after
he had scratched his arms following an altercation with another youth.
Nelson told the counselor that he often got depressed and mutilated
himself after getting into trouble. Suicide precautions were discontinued
several days later.

1

}:

» Lindsay M. Hayes, M.S., is

I Assistant Director of the National

I Center on Institutions and

i ’ Alternatives. He has conducted

research, provided technical
assistance and training, and
served as an expert u/itness in the
area of jail, prison, and juvenile
suicide for the past 20 years.

BEST

In June 1997, Nelson was place(i in a
quiet room for several hours after he was
ju(ige(i a risk to himself because he h^d
inflicte(i superficial scratches on his arms
^nd a risk to others because he threat-
ene(i his peers. He later told unit staff
that placement in the quiet room dimin-
ished his need to abuse himself (some-
times he would punch the walls to relieve
his tension and anger). In July 1997,
Nelson was again housed in a quiet room
and placed on suicide precautions after
threatening suicide. In December 1997,
cottage staff referred him to a counselor
as they were concerned about his depres-
sion and his questioning whether “life
was worth living anymore.” He was

' To ensure confidentiality, the names of the
victim and facility have been changed.

reportedly upset by the likelihood of be-
ing transferred to another facility because
of his noncompliance with the treatment
program. The situation was exacerbated
by his mother’s decision to stop visiting
him in order to encourage his participa-
tion in treatment. The counselor be-
lieved that suicide precautions were
unnecessary, and Nelson agreed to notify
staff should he feel suicidal again.

On January 12, 1998, at approximately
5:30 p.m.. Nelson was placed in a quiet
room as a discipline for flashing gang signs
in the dining room and making sexual
comments about female cottage staff. Cot-
tage staff returned Nelson — ^who appeared
quiet and lonely to his peers — to his hous-
ing cottage at approximately 6:50 p.m.

At approximately 10:30 p.m., cottage staff
found Nelson in his room hanging from a

Suicide Prevention in Juvenile Facilities

ceiling vent by a sheet. Staff initiated car-
diopulmonary resuscitation and called for
an ambulance. Paramedics arrived shortly
thereafter, continued lifesaving measures,
and transported the youth to a local hos-
pital where he died a few days later as a
result of his injuries.

Prevalence

Nelson’s death is one of an undetermined
number of suicides that occur each year
in public and private juvenile facilities
throughout the Nation. According to the
Centers for Disease Control and Preven-
tion (CDC), the suicide rate of adoles-
cents ages 15 to 19 has quadrupled from
2.7 suicides per 100,000 in 1950 to 11
suicides per 100,000 in 1994 (Centers for
Disease Control and Prevention, 1995).
CDC also reported that more teenagers
died of suicide during 1994 than of can-
cer, heart disease, acquired immune defi-
ciency syndrome, birth defects, stroke,
pneumonia and influenza, and chronic
lung disease combined.

Several national studies have examined
the extent and nature of suicide in jail
and prison facilities (Hayes, 1989, 1995),
but there has been little comparable na-
tional research regarding juvenile suicide
in secure detention or confinement. The
only national survey of juvenile suicides
in secure custody (Flaherty, 1980) re-
flected a problematic calculation of sui-
cide rates. Reanalysis of suicide rates in
that study found that youth suicide in
juvenile detention and correctional fa-
cilities was more than four times greater
than youth suicide in the general popula-
tion (Memory, 1989). Accurate data on
the total scope and rate of juvenile sui-
cide in custody are still lacking.

The U.S. Bureau of the Census has been
collecting data on the number of deaths
of juveniles in custody since 1989. In the
first year of the survey, juvenile officials

self-reponed 17 suicides in public deten-
tion centers, reception and diagnostic
centers, and training schools during 1988
(Krisberg et al., 1991). Fourteen such sui-
cides were reported during 1993 (Austin
et al., 1995). Given the epidemiological
data regarding adolescent suicide, coupled
with the increased risk factors associated
with detained and confined youth, the
reported number of suicides in custody
appears low. The National Center for
Health Statistics, however, reported that
30,903 persons committed suicide in the
United States in 1996. Of these, approxi-
mately 7 percent (2,1 19) were youth age
19 or younger. For youth younger than age
15, suicides increased 113 percent between
1980 and 1996 (Snyder and Sickmund,
1999). Because of statistics like these, many
juvenile justice experts and practitioners
believe that suicides are underreported. To
date, no comprehensive study of deaths in
custody has been undertaken.

Suicide in juvenile detention and
correctional facilities was more than four
times greater than youth suicide overall.

Risk Factors

Brent (1995) identified mental health
disorder and substance abuse as the most
important set of risk factors for adoles-
cent suicide. Other risk factors include
impulsive aggression, parental depression
and substance abuse, family discord and
abuse, and poor family support. Life stres-
sors, specifically interpersonal conflict
and loss and legaLand disciplinary prob-
lems, were also associated with suicidal
behavior in adolescents, particularly sub-
stance abusers. Many of these risk factors
are prevalent in youth confined in ju-
venile facilities (Alessi et al., 1984;
Rohde, Seeley, and Mace, 1997).

3

Volume VII • Number 1 25

Juvenile Justice

Although there are insufficient national
data regarding the incidence of youth
suicide in custody, information suggests
a high prevalence of suicidal behavior in
juvenile correctional facilities. According
to a study funded by the Office of Juvenile
Justice and Delinquency Prevention, more
than 11,000 juveniles engage in more
than 17,000 incidents of suicidal behavior
in juvenile facilities each year (Parent et
al., 1994). In addition, the limited re-
search on juvenile suicide in custody sug-
gests that confined youth may be more
vulnerable to suicidal behavior based on
current or prior suicidal ideation (i.e.,
thoughts and/or ideas of hurting or killing
oneselO. For example, one study found
that incarcerated youth with either major
affective disorders or borderline personal-
ity disorders had a higher degree of sui-
cidal ideation and more suicide attempts
than comparable adolescents in the gen-
eral population (Alessi et al., 1984).

Policies to provide close observation of
suicidal residents did not appear to
significantly reduce suicidal behavior*

Other studies found that a high percent-
age of detained youth reported a history
of suicide attempts (Dembo et al., 1990)
and psychiatric hospitalization (Waite,
1992) and current and active suicidal
behavior (Davis et al., 1991). Two re-
cent studies of youth confined in a ju-
venile detention facility found that
suicidal behavior in males was associ-
ated with depression and decreased so-
cial connection, while suicidal behavior
in females was associated with impulsiv-
ity and instability (Mace, Rohde, and
Gnau, 1997; Rhode, Seely, and Mace,
1997). Finally, other researchers found
high rates of suicidal behavior (Duclos,
LeBeau, and Elias, 1994) and psychiatric
disorders (Duclos et al., 1998) among

American Indian youth confined in
juvenile facilities.

Conditions of
Confinement

In August 1994, the Office of Juvenile
Justice and Delinquency Prevention
published Condidom o/Con/mement:
Juvenile Detention and Corrections Facilities
(Parent et al., 1994). The study described
in that Report investigated several con-
ditions of confinement within juvenile
facilities, including suicide prevention
practices. Using four specific assessment
criteria to evaluate suicide prevention
practices — written procedures, intake
screening, staff training, and close
observation — the study found the
following;

^ Only 25 percent of confined juveniles
were in facilities that conformed to all four
suicide prevention assessment criteria.

^ Facilities that conducted suicide
screening at admission and trained staff in
suicide prevention had fewer incidents of
suicidal behavior among their residents.

^ Suicidal behavior increased for youth
housed in isolation.

^ Written policies to provide close ob-
servation of suicidal residents did not ap-
pear to significantly reduce the rate of
suicidal behavior. Because these policies
are typically implemented after the risk
or attempt is recognized, however, they
may reduce the number of suicides.

Critical Components
of a Suicide Prevention
Policy

The American Correctional Association
(ACA), the National Commission on
Correctional Health Care (NCCHC), the
National Juvenile Detention Association

Suicide Prevention in Juvenile Facilities

(NJDA), and other national organizations
have long advocated comprehensive sui-
cide prevention programming. ACA and
NCCHC have promulgated national de-
tention and corrections standards that
are adaptable to individual juvenile facili-
ties. While the ACA standards are more
widely recognized, the NCGHC standards
offer more comprehensive guidance regard-
ing suicide prevention and identify the
recommended ingredients for a suicide pre-
vention plan: identification, training, as-
sessment, monitoring, housing, referral,
communication, intervention, notification,
reporting, review, and critical incident de-
briefing (National Commission on Correc-
tional Health Care, 1999). NJDA has
developed a suicide prevention curriculum
that is incorporated into its detention staff
basic training course. Using a combination
of ACA and NCCHC standards, the au-
thor has developed a comprehensive sui-
cide prevention plan for juvenile facilities
that addresses the following key compo-
nents: staff training, intake screening and
ongoing assessment, communication, hous-
ing, levels of supervision, intervention, re-
porting, and followup/mortality review.
These components form a continuum of
care intended to minimize suicidal behav-
ior within secure juvenile detention and
correctional facilities.

Staff Training

The essential component of a successful
suicide prevention program is properly
trained staff — the backbone of any ju-
venile facility. Mental health, medical,
or other program staff prevent few sui-
cides because juveniles usually attempt
suicides in housing units during late
evening hours or on weekends, when
program staff are absent. Accordingly,
suicide attempts must be thwarted by
direct-care staff who have been trained
in suicide prevention and have devel-
oped an intuitive sense about the youth
under their care.

All direct-care, medical, and mental
health personnel, in addition to any
staff who have regular contact with
youth, should receive 8 hours of initial
suicide-prevention training, followed
by 2 hours of refresher training each
year. The initial training should address
the reasons the environments of juve-
nile facilities are conducive to suicidal
behavior, factors that may predispose
youth to suicide, high-risk suicide
periods, warning signs and symptoms,
components of the facility’s suicide pre-
vention policy, and liability issues asso-
ciated with juvenile suicide. The 2-hour
refresher training should review the pre-
disposing risk factors, warning signs and
symptoms, and any changes to the
facility’s suicide prevention plan and
discuss any recent suicides or suicide
attempts in the facility.

Intake Screening and
Ongoing Assessment

Intake screening and ongoing assessment
of all confined youth are critical to a juve-
nile facility’s suicide-prevention efforts.
Although youth can become suicidal at
any point during their confinement, the
following periods are considered times
of high risk (National Commission on
Correctional Health Care, 1999):

O

Volume VII • Number 1 27

© 1999 Corbis

Juvenile Justice

♦ tXiring initial admission.

On return to the facility from court
after adjudication.

^ Following receipt of bad news or
after suffering any type of humiliation
or rejection.

^ tXiring confinement in isolation or
segregation.

^ Following a prolonged stay in the
facility.

Suicide prevention begins at the point
of arrest.

Intake screening for suicide risk may be
included in the medical screening form
or on a separate form. The screening pro-
cess should obtain answers to the follow-
ing questions:

Was the youth considered a medical,
mental health, or suicide risk during any
previous contact or confinement within
this facility?

^ Does the arresting or transporting of-
ficer have any information (e.g., from ob-
served behavior, documentation from the
sending agency or facility, conversation
with a family member or guardian) that
indicates the youth should currently be
considered a medical, mental health, or
suicide risk?

^ Has the youth ever attempted suicide?

^ Has the youth ever considered suicide?

^ Has the youth ever been or is the
youth currently being treated for mental
health or emotional problems? ..

^ Has the youth recently experienced a
significant loss (e.g., job, relationship,
death of a family member or close friend)?

^ Has a family member or close friend
ever attempted or committed suicide?

♦ Does the youth express helplessness or
hopelessness and feel there is nothing to
look forward to in the immediate future?

♦ Is the youth thinking of hurting or
killing himself or herself?

To make a thorough and complete assess-
ment, the intake process should also in-
clude procedures for referring youth to
mental health or medical personnel.
Following the intake process, a procedure
should be in place that requires staff to
take immediate action in case of an
emergency. If staff hear a youth verbalize
a desire or intent to commit suicide, ob-
serve a youth engaging in self-harm, or
otherwise believe a youth is at risk for
suicide, they should constantly observe
the youth until appropriate medical,
mental health, or supervisory assistance
can be obtained.

Communication

Certain behavioral signs exhibited by
youth may indicate suicidal behavior.
Detection and communication of these
signs to others can reduce the likelihood
of suicide. Direct-care staff who establish
trust and rapport with youth, gather per-
tinent information, and take action can
prevent many juvenile suicides (Roush,
1996). There are three paths of commu-
nication in preventing juvenile suicides:
between the arresting or transporting of-
ficer and direct-care staff; between and
among facility staff (including direct
care, medical, and mental health person-
nel); and between facility staff and the
suicidal youth.

In many ways, suicide prevention begins
at the point of arrest. Close observation
of what youth say and how they behave
during arrest, transport to the facility,
and intake are crucial in detecting sui-
cidal behavior. The scene of arrest is
often the most volatile and emotional
time, so arresting officers should pay

0^3

ERIC

V

6

Copyright © 1999 Corbts

Suicide Prevention in Juvenile Facilities

particular attention to youth during this
time: The anxiety or hopelessness of the
situation can provoke suicidal behavior,
and onlookers such as family members,
guardians, and friends can provide infor-
mation on any previous suicidal behav-
ior. The arresting or transporting officer
should communicate any pertinent infor-
mation regarding the well-being of the
youth to direct-care staff. It is also criti-
cal for direct-care staff to maintain open
lines of communication with parents or
guardians, who often have pertinent in-
formation regarding the mental health
status of residents.

During intake and screening, effective
management of suicidal youth is based on
communication between direct-care per-
sonnel and other professional staff in the
facility. Because youth can become sui-
cidal at any point during confinement,
direct-care staff should be alert, share in-
formation, and make appropriate referrals
to mental health and medical staff. The
facility’s shift supervisor should ensure
that direct-care staff are properly in-
formed of the status of each youth desig-
nated for suicide precautions and should
similarly brief the incoming shift supervi-
sor. Interdisciplinary team meetings to
discuss the status of youth designated for

suicide precautions should occur on a
regular basis and include direct-care,
medical, and mental health personnel.
Finally, the authorization for suicide pre-
cautions, any changes in these precau-
tions, and the observations made of
youth designated for precautions should
be documented on specific forms and
distributed to appropriate staff.

Housing

When determining the most appropriate
housing location for a suicidal youth, ju-
venile facility officials often physically
isolate and restrain the individual with
the concurrence of medical or mental
health staff. These responses may prove
detrimental to the youth. Isolation in-
creases the sense of alienation and further
removes the individual from proper staff
supervision (Parent et al., 1994). Housing
assignments should maximize staff inter-
action with the youth and avoid height-
ening the depersonalizing aspects of
confinement. Suicidal youth should be
housed in the general population, mental
health unit, or medical infirmary, where
the youth is close to staff. Removing a
youth’s clothing (with the exception of
belts and shoelaces) and using physical
restraints should be done only as a last
resort when the youth is physically
engaging in self-destructive behavior.

Rooms designated to house suicidal youth
should be suicide-resistant, free of signifi-
cant protrusions, and provide full visibility
(including room doors with clear panels
large enough to provide staff with unob-
structed interior views). Finally, each
housing unit in the facility should contain
emergency equipment, including a first-
aid kit, pocket mask or face shield, Ambu-
bag, and a rescue tool that cuts through
fibrous material. Direct-care staff should
ensure, on a daily basis, that such equip-
ment is in working order.

Juvenile Justice

Supervision

Promptness of response to suicide at-
tempts in juvenile facilities is often driven
by the level of supervision. Medical evi-
dence suggests that brain damage from
strangulation caused by a suicide attempt
can occur within 4 minutes and death can
occur within 5 to 6 minutes (American
Heart Association, Emergency Cardiac
Care Committee and Subcommittees,
1992). Two levels of supervision are rec-
ommended for suicidal youth: close obser-
vation and constant observation. Close
observation is reserved for youth who are
not actively suicidal but express suicidal
thoughts (e.g., expressing a wish to die
without a specific threat or plan) or have
a recent history of self-destructive behav-
ior. Staff should observe such youth at
staggered intervals not to exceed 15 min-
utes. Constant observation is reserved for
youth who are actively suicidal — either
threatening or engaging in suicidal behav-
ior. Staff should observe such youth on a
continuous, uninterrupted basis. Some
jurisdictions use an intermediate level of
supervision with observation at staggered
intervals that do not exceed 5 minutes.
Other aids (e.g., closed-circuit television
and roommates) can be used as a supple-
ment to, but never as a substitute for,
these observation levels. Finally, mental
health staff should assess and interact
with — not just observe — suicidal youth
on a daily basis. A careful assessment
should be made of the youth’s underlying
mental health needs, and a plan should
be developed to address those needs.

Intervention

The manner and promptness of the staff’s
intervention after a suicide attempt often
determine whether the victim will sur-
vive. Providing competent training and
establishing an effective system of com-
munication can facilitate this interven-
tion process. First, all staff who come into

— ^ 8

contact with youth should be trained in
first-aid procedures and cardiopulmonary
resuscitation (CPR). Second, any staff
member who discovers a youth engaging
in self-harm should immediately survey
the scene to assess the severity of the
emergency, alert other staff to call for
medical personnel, if necessary, and be-
gin first aid or CPR. Third, staff should
never presume that the youth is dead;
rather, they should initiate and continue
appropriate life-saving measures until
they are relieved by arriving medical per-
sonnel. In addition, medical personnel
should ensure daily that equipment used
in responding to an emergency within
the facility is in working order. Finally,
although not all suicide attempts require
emergency medical intervention, mental
health staff should intervene and assess
all suicide attempts.

Reporting

In the event of a suicide attempt or sui-
cide, appropriate officials should be noti-
fied through the appropriate chain of
command. Following the incident, the
victim’s family and appropriate outside
authorities should be notified immedi-
ately. Staff who came into contact with
the victim before the incident should
submit a statement that details their
knowledge of the youth and the incident.

Followup

A juvenile suicide is extremely stressful
for staff and residents. Staff may feel os-
tracized by fellow personnel and admin-
istration officials; the direct-care worker
may display misplaced guilt, wondering
“What if I had made my room check
earlier?”; and residents are often trauma-
tized by critical events occurring within
a facility. When crises occur, staff and
residents should be offered immediate
assistance. One form of assistance is
Critical Incident Stress Debriefing

V

Suicide Prevention in Juvenile Facilities

(CISD). A CISD team, comprising
professionals trained in crisis interven-
tion and traumatic stress awareness
(e.g., police officers, paramedics,
firefighters, clergy, and mental health
personnel), provides affected staff and
residents an opportunity to process their
feelings about the incident, develop an
understanding of critical stress symp-
toms, and develop ways of dealing with
them (Meehan, 1997; Mitchell and
Everly, 1996). For maximum effective-
ness, the CISD process or other appro-
priate support services should occur
within 24 to 72 hours of the critical
incident.

Every suicide and serious suicide attempt
(i.e., attempts requiring medical treat-
ment or hospitalization) should be exam-
ined through a mortality review process.

If resources permit, clinical review of sui-
cide through a psychological autopsy —
a retrospective reconstruction of the
victim’s life — is also recommended
(Sanchez, 1999). Ideally, the mortality
review should be coordinated by an out-
side agency to ensure impartiality and
should be separate from other formal in-
vestigations that may be required to de-
termine the cause of death. The review
should include a critical inquiry of the
following aspects of the case:

^ Circumstances surrounding the
incident.

^ Facility procedures relevant to the
incident.

^ All relevant training received by
involved staff.

^ Pertinent medical and mental health
services and reports involving the victim.

^ Recommendations, if any, for changes
in policy, training, physical plant, medi-
cal or mental health services, and opera-
tional procedures.

Conclusion

“For every two youth (ages 0-19) mur-
dered in 1996, one youth committed
suicide” (Snyder and Sickmund,

1999:24). Youth suicide is recognized as a
serious public health problem, but suicide
within juvenile facilities has not received ,
comparable attention, and the extent
and nature of these deaths remain un-
known. Collaborative efforts among
child-serving agencies and technical as-
sistance training for juvenile facility staff
are just two of the components that are
essential for suicide prevention within
secure juvenile detention and correc-
tional facilities. Now is the time to focus
additional attention and resources on
preventing suicide within these facilities.

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Services and Disaster Workers, 2d ed. Ellicott City,
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Parent, D.G., Leiter, V., Kennedy, S., Livens, L.,
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